Monday, February 3, 2014

With a billion dollars riding on the contested decision, Florida's Agency for Health Care Administration says it will award its Medicaid managed-care contract for Miami-Dade and Monroe counties to Prestige Health Choice.

The final order, signed by AHCA Secretary Liz Dudek on Friday, rejects a recommendation from an administrative law judge who held hearings in the case in November. The judge, John Van Laningham, wrote that the corporate structure of Prestige Health Choice did not meet the definition for a "provider service network," or PSN.

Care Access, the company that filed the protest that led to the hearings, issued a statement Monday expressing disappointment. The company plans to file an appeal with the First District Court of Appeal in Tallahassee, the statement says.

Each region of the state must offer a PSN as a choice for Medicaid enrollment, in addition to HMOs. So if Prestige was not a true PSN, then the contract would have to be awarded to a competitor. Care Access PSN, which brought the protest that led to the hearing, stood to inherit the contract if Prestige were not eligible.

Van Laningham said Prestige did not have majority ownership by doctors or other health-care providers, a requirement for designation as a PSN. Florida True Health, a company formed by two insurers, Florida Blue and AmeriHealth Caritas, owns 40 percent of Prestige. In addition, the judge said, Florida True Health holds an option to purchase the other 60 percent of shares.

Another 13 percent of Prestige is owned by Florida Health Choice Network, which is a consortium of neighborhood health centers. Van Laningham ruled that that Florida Health Choice Network is not a Medicaid provider, so therefore Prestige could not qualify as a PSN. His decision was issued on Jan. 2, and Health News Floridafiled this report.

State agencies and boards can overrule the recommendations of hearing officers if they can cite specific errors in the legal reasoning used to arrive at a decision. They cannot override findings of fact.

In its ruling, AHCA said Van Laningham had misconstrued two sections of the law that established the statewide managed-care Medicaid program.

AHCA went ahead and signed a contract with Prestige to enroll patients in Miami-Dade, along with seven other regions of the state (see list of plans by region). The three regions in which other PSNs were chosen were Region 2, Panhandle, Better Health Plan; Region 4, Northeast Florida, First Coast Advantage; and Region 10, Broward County, South Florida Community Care Network.

Frank Reiner, attorney for Care Access, says the law requires AHCA to hold off on issuing the contract until the 1st District Court has ruled in the coming appeal. Health News Florida raised that question with AHCA Monday afternoon, but had not yet heard back by 6 p.m.

Miami-Dade has been hotly contested because it has the most Medicaid enrollees, and therefore the most potential new customers, for whom the state pays the premiums. The Miami-Dade contract is expected to pay about $1 billion over five years, a Care Access spokeswoman said.

The Legislature created the law in 2011 that requires virtually all Medicaid beneficiaries -- including those in long-term care -- to enroll in a managed-care plan, either an HMO or a PSN. The Long-Term-Care rollout is under way, and the other beneficiaries will be shifted between May and August of this year.

The law does away with "fee-for-service" Medicaid payments, in which doctors, hospitals and other providers directly billed the state. Amid the gush of claims, the state found it difficult to prevent fraud and abuse. By privatizing the program -- turning management of treatment and payment over to managed-care plans -- Medicaid becomes a regulator, rather than a direct payer.

While HMOs and PSNs may seem similar from the point of view of the patient, an HMO is a commercial operation that is dually licensed by AHCA and the Office of Insurance Regulation. A PSN is a health-care network owned and run by the health-care professionals who treat the patients.

More information on the Statewide Medicaid Managed Medical Assistance Program is available here.

Florida moves to open a state-run exchange

Florida may soon be operating its own health insurance exchange. The state has become a well known opponent of the Affordable Care Act , going so far as to seek the dismantling of the federal health care reform law through the Supreme Court as well as banning insurance navigators from working in the state. The state has missed its deadline to develop and operate a working exchange last year, meaning that a federal exchange has been set up for the state’s residents. Now, however, Florida Health Choices may soon be offering coverage.

Exchange finally shows signs of life after years of dormancy

Florida Health Choices was first established through state law in 2008. Since then, however, little has been done in regards to developing the exchange. Most of Florida’s legislative focus has been committed to opposing the health care reform law, but the state has found little success in this endeavor. State officials suggest that allowing the federal government to manage the health insurance market is dangerous and claim that the state should have more authority over the market. As such, Florida Health Choices is preparing to open itself to the public.

State-run exchange will not compete with the federal government

There is no news concerning which of the state’s insurance companies will be providing coverage through the state-run exchange. Rose Naff, CEO of Florida Health Choices, claims that the majority of Floridians are not purchasing coverage through the federal insurance exchange. Instead, these people are purchasing coverage through the private market. Naff suggests that the state-run health insurance exchange will not be competing with the federal government when it comes to selling policies.

STATE-RUN EXCHANGE EXPECTED TO BECOME OPERATIONAL IN EARLY FEBRUARY

Naff anticipates that the launch of the state-run exchange is only “a few days” away. The exchange is expected to begin operation in early to mid-February and will provide subsidies for consumers that can help them acquire the insurance coverage they need. The state-run exchange is expected to operate in a similar fashion to exchanges in other states, with Florida officials keen to ensure that the federal government has little control over the exchange itself.

PITTSBURGH – In a creative, community-wide competition to spark fresh ideas that engage people in their own health care, the University of Pittsburgh is offering $300,000 in funding to three winners in its first Pitt Innovation Challenge, or PInCh.

Just as a reality TV show gives contestants an opportunity to share their inventions, PInCh will give scientists and other community members a venue to be creative and develop new ideas, said CTSI director Steven Reis, M.D., who also is associate vice chancellor for clinical research, health sciences, and a professor of medicine at the University of Pittsburgh School of Medicine. PInCh’s inaugural question is: “How do we empower individuals to take control of their own health outcomes?”

“Instead of trying to figure out the molecular mechanisms of hypertension, for example, the team might try to figure out how to reduce the rate of high blood pressure in a specific region,” Reis said. “We want to encourage researchers to approach their work in a different way. Rather than conducting experiments focused on scientific details, they must look at the big picture to try to solve a problem that has public health or clinical importance.”

According to PInCh program director John Maier, M.D., Ph.D., director of research and development and assistant professor, Department of Family Medicine, Pitt School of Medicine, the first step in the competition requires submitting a two-minute video by March 2 that introduces the team, defines the health problem that is being tackled and briefly outlines the creative solution. Early round winners will be invited to a final round of judging in May at a public event in which teams will make short presentations to a panel of judges.

“This will be a great opportunity to get new or risky ideas in front of judges who have experience in science, business, technology and other fields, so participation itself should be rewarding and fun,” Maier said. “We plan to have a ‘People’s Choice’ award, too, so everyone will have a chance to vote for projects that appeal to them.”

Anyone can enter, and teams that bring together collaborators from different perspectives, institutions and disciplines are encouraged, but at least one member of the team must be a Pitt faculty member. If needed, PInCh organizers will help community members connect with a member of the faculty. The solution could be a device, a software application, an intervention strategy or any other approach that could address the health problem the team identifies.

“We hope to de-risk wild ideas to solve clinical or public health problems by providing funding and project management to take them to the next level,” Reis said. “We think some amazing ideas will come out of this process, and we hope the PInCh model can be used in future competitions to stimulate innovative solutions to challenging issues.”

“Without continual growth and progress, such words as improvement, achievement, and success have no meaning.” – Benjamin Franklin

HCMS

Health Care Management Systems was created to provide free, high quality, on-demand learning to all of those involved in the frontlines of healthcare!

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You see, this story begins about 3 years ago on the Texas gulf coast when two unlikely partners teamed up to change the way managed care was delivered to a certain Medicare population.

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Lighting in a Bottle –

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To ensure that this tool will continue to be available to all of those we serve, we have teamed up with other healthcare leaders to provide employer sponsored learning as well.

A big THANK YOU to all of our partners and sponsors – without them none of this would be possible….

To find out how you can partner with us to ensure equal access to quality education email: kgifford@ermconsultinginc.com.

How Do I Sign Up?

HCMS ACADEMY-

We invite everyone currently working on the frontlines or those contemplating a new career in healthcare to register for the HCMS Academy. Register for free courses and receive certifications in Medicare Risk Adjustment, ICD-10 Coding and Rapid Practice Innovation. As a member of the Academy you are invited to join our conversation on the “Innovation X-Change.” The X-Change provides a secure, HIPPA compliant meeting space for visionaries to share ideas and collaborate on future projects. Join a group or start your own. Register today at www.globalhcms.org – What are you waiting on – it’s totally FREE!

SPONSOR E-LEARNING-

Are you involved in health care? If so, we invite you to join us in our mission! By sponsoring e-learning for your employees or industry partners you can help ensure that everyone has equal access to high quality education.

By partnering with HCMS, you extend our proven education to your organization at no cost and we are able to provide you with state of the art analytics including dashboards to track implementation and progress across large organizations in real time. This system was built on an API that accepts up to 5 data sources which potentially allows us to measure and analyze financial, educational and utilization data together for the first time. All of this at a fraction of the cost of traditional analytics.

To learn more about how we can partner for a better tomorrow, please contact: kgifford@ermconsultinginc.com